The association between dental caries and
anthropometric measures in 5-9 year old
Bangladeshi children
Masuma Pervin Mishu
PhD student (Dental Public Health)
Department of Epidemiology and Public Health
Supervisors:
Prof. Richard G Watt
Dr. Georgios Tsakos
Prof. Aubrey Sheiham
Dr. Anja Heilmann
Presentation overview
• Background and literature review
• Gaps in current knowledge
• Aim and objectives
• Methods
• Pilot study
• Future work plan
2
Background: Dental Caries
Dental caries is a major public
health problem affecting 60%90% of children globally. In most
low-income countries more than
90% of decay remains untreated.
(Petersen et al. 2005; Edelstein 2006;
Bagramian et al. 2009).
Dental caries
3
Relationship between dental caries
and children’s height and weight
4
High-income countries
• Association between higher levels of dental caries and
higher BMI (Hayden et al. 2013).
• The major causes of the dental caries and higher BMI are
similar – sugary foods and drinks
( Swinburn et al. 2004; Moynihan
& Petersen 2004; Hooley et al. 2012a).
5
Low-income countries
• Inverse relationship between caries and children’s height,
weight and BMI (Alkarimi et al. 2014; Mishu et al. 2013; Benzian et al. 2011).
• Dental treatment followed by greater weight gain.
(Acs et al. 1999; Malek Mohammadi et al. 2009; Acs & Lodolini 1998; Monse et al. 2012).
6
Hypothesised mechanisms linking
untreated caries with compromised growth
7
Dental caries
(leading to dental pain and infection)
Impact on oral health related
quality of life
Poor
Appetite
Impact on
eating/chewing
Impact on
sleeping
Reduced food
intake
Disturbed slow
wave sleep
Malnutrition
Growth hormone
disturbance
Compromised growth
(Adapted from Sheiham 2006, Alkarimi et al.2014)
8
Oral Health Related Quality of Life
(OHRQoL)
Measures of the extent that oral status and conditions
disrupt normal social-role functioning and bring about major
changes in behaviour (Locker, 1989).
9
Important domains of oral health related
quality of life (OHRQoL)
Oral
symptoms
Functional
Oral health related
quality of life
Social
Psychological
10
Why measure oral health related quality of
life (OHRQoL) in young children?
Oral diseases have a negative impact on the functional,
social and psychological well-being of children and their
families.
(Pahel et al. 2007; Filstrup et al. 2003; Do & Spencer 2007).
11
Different scales to measure OHRQoL
• Self-reported scale for children.
• Parental proxy report for children.
• Combination of self and proxy report.
• Measures of the impact of the oral health of child on the
life of the family.
12
Dental caries adversely affects OHRQoL
• Higher caries level is significantly associated with overall
poorer OHRQoL (Barbosa & Gavião 2008).
• Dental treatment is associated with improved quality of life
(Alkarimi et al. 2012, Thomas & Primosch 2002a), and
weight gain
(Duijster et al. 2013).
13
Dimensions of OHRQoL most relevant to
child growth: pain, eating and sleeping
14
1. Dental pain
• Dental caries is a common cause of dental pain in
childhood.
• Dental pain is highly prevalent among children and the
prevalence ranging from 5-33%.
• There is 5% to 6% increase in probability of toothache for
each additional deciduous tooth with caries experience
(Slade 2001).
15
Impact of dental pain on child growth
• Direct impact of dental pain and infection:
Increase of glucocorticoid production in response to dental
pain may affect normal growth and general health of children
with Severe Early Childhood Caries (SECC)
(Acs et al. 1992; Ayhan et al. 1996; Ohlund et al. 2007).
16
Impact of dental pain on child growth
(Continued)
• Indirect impact of dental pain:
Dental pain affects eating/chewing and sleeping.
(Moura-Leite et al. 2011; Moura-Leite et al. 2008; Bönecker et al. 2012;
Shepherd et al. 1999).
17
Dental caries
(leading to dental pain and infection)
Impact on oral health related
quality of life
Poor
Appetite
Impact on
eating/chewing
Impact on
sleeping
Reduced food
intake
Disturbed slow
wave sleep
Malnutrition
Growth hormone
disturbance
Compromised growth
(Adapted from Sheiham 2006; Alkarimi et al. 2014)
18
2. Effect of dental caries on diet
• Changes in the diet from solid to liquid or semi-liquid,
reduced ability to eat a varied diet resulting in reduction of
caloric intake (Vania et al 2011; Clarke et al., 2006).
• Impedes achievement of dietary goals related to the
consumption of fruits, vegetables and non starch
polysaccharide (NSP) (Moynihan & Petersen 2004).
19
Effect of dental caries on diet (continued)
• Relatively poor nutritional health with lower vitamin D,
calcium, and albumin concentrations (Schroth et al. 2013).
• Increased risk of iron deficiency anemia
(Clarke et al. 2006;
Schroth, Levi, et al. 2013).
20
Dental infection and poor appetite
• Infection from dental caries and pulpal involvement may
reduce appetite of children
(Langhans 1996; Plata-Salamán 1996);
decreased food consumption may lead to under nutrition
(Stephensen 1999).
• Dental treatment can improve a child’s appetite
(Alkarimi et al.
2012).
21
Dental caries
(leading to dental pain and infection)
Impact on oral health related
quality of life
Poor
Appetite
Impact on
eating/chewing
Impact on
sleeping
Reduced food
intake
Disturbed slow
wave sleep
Malnutrition
Growth hormone
disturbance
Compromised growth
(Adapted from Sheiham 2006, Alkarimi et al.2014)
22
3. Effect of sleep disturbance on growth
• Inhibition of Slow Wave Sleep (SWS) may cause inhibition
of growth hormone (GH) release.
• Pain induced stress and nervousness may cause more
glucocorticoid secretion and deeper inhibition of GH
release (Acs et al. 1992; Vania et al. 2011; Sheiham 2006).
23
Dental pain and sleep disturbance
• Dental pain is a common cause of sleep disturbance in
children
(Acharya & Tandon 2011)
and dental treatment can
improve sleep (Thomas & Primosch 2002).
• Decreases in oral health impacts on sleeping appeared to
be the most important factor for weight gain after dental
treatment (Duijster et al. 2013).
24
In summary
Impact on child’s growth
Dental pain and poor OHRQoL
25
Gaps in current knowledge
• There is inconsistency in the association between dental caries and
anthropometric measures.
• Several studies examined limited range of caries and BMI levels and
not all used age-and gender-adjusted standard measures of BMI.
• Underlying mechanisms of negative association between caries and
anthropometric measures not examined in depth.
• Effects of individual important dimensions of OHRQoL on
anthropometric measures rarely studied.
26
Gaps in current knowledge
• Factors such as loss of appetite, chewing ability, changes
in food choice, or sleeping patterns not explored in depth.
• Most studies did not use validated instruments.
• Currently,
no
validated
version
of
any
OHRQoL
questionnaire for children available in Bengali.
27
Study Aims
• To assess the associations between dental caries status
and anthropometric measures among 5 to 9 year old
Bangladeshi children.
• To consider the potential role of oral health related
quality of life, particularly that of dental pain, poor
appetite, and problems with eating and sleeping, in the
association between dental caries and anthropometric
measures.
28
Objective 1
To adapt the “Scale of Oral Health Outcomes for 5-year-old
children” (SOHO-5) to the Bengali language and to evaluate
the validity and reliability of the Bengali version of the
SOHO-5.
29
Objective 2
To examine the association between severity of dental caries
and anthropometric measurements (age adjusted height and
weight, and BMI-z-scores).
Working hypothesis: the severity of dental caries will be
inversely associated with children’s height, weight and BMI.
30
Objective 3
To explore the role of OHRQoL on the association between
dental caries and anthropometric measurements of the
children
Working hypothesis: anthropometric measurements in 5-9
year old Bangladeshi children are affected through the
impacts of dental caries on children’s OHRQoL.
31
Objective 4
To explore the role of dental pain, eating and sleeping
difficulties and poor appetite due to dental caries on the
association between dental caries and anthropometric
measurements of the children.
Working hypothesis: the association between dental caries
and anthropometric measurements will be attenuated after
adjusting for dental pain, appetite and difficulties with eating
and sleeping.
32
Study Methods
33
Study design
• Cross-sectional observational study.
• Study population: 5-9 year old children.
34
Why 5-9 year olds?
1. Growth between the ages of 5 to 9 years relatively stable
(no pubertal growth change yet).
2. Ability to answer a self-reported pain and problem related
questionnaire improves considerably from the age of 5.
3. WHO growth reference data are available for two age
groups: 0-59 months and 5-19 years (WHO 2007).
35
Study location-Bangladesh
36
Study location
Dhaka city
Dhaka dental college and
hospital
37
Recruitment of study participants
Department of paediatric
dentistry, DDCH
Primary schools
38
Ethical approval and consents
• Ethical approval obtained from the UCL Research Ethics Committee.
• Ethical approval from ‘National Research Ethics Committee of
Bangladesh’ through the Bangladesh Medical Research Council
(BMRC).
• Permission from director of Dhaka Dental College Hospital.
• Principals of two primary schools to run the study in their institutions.
• The parents will be asked for consent before their and their child’s
participation. Participation will be voluntary and anonymous.
39
Inclusion and exclusion criteria
Inclusion criteria
• All children aged 5-9 years coming for dental treatment to
DDCH in the months of data collection.
• All school children of this age group in the 2 primary
schools.
Exclusion criteria
• Children with any systemic diseases.
• Children with any acute infections, fever and diarrhoea
during the week preceding the data collection.
• Children not getting parental consent.
40
Data collection procedures
Study participants
Children
Clinical data
Clinical dental
data
Parents
Non-clinical data
Non-clinical data
(interviewer administered
questionnaires)
(Self- administered
questionnaires)
Anthropometric
data
41
Collection of clinical dental data
By a dental survey through clinical dental examination using standard
World Health Organization – Oral Health Survey Basic Methods-2013
(WHO 2013).
42
Anthropometric measurements
• Weight and height will be measured by the same
examiner according to the Food and Nutrition
Anthropometric Indicators Measurement Guide
(Cogill 2001).
43
Weight and height measurement:
Weight will be measured by using a pre-calibrated digital Seca scale.
Height will be measured by using a portable stadiometer.
44
Questionnaire translation
• The questionnaires for the field studies were designed in
English and translated into Bengali through forwardbackward translation.
• Carried out with sensitivity to the local culture.
45
Summary of variables
Outcomes
Main exposure
Mediators
Covariates
•
•
•
OHRQoL.
•
•
Dental pain.
•
Appetite.
•
Eating
Height-for-age zscore.
•
Weight-for-age z-
Untreated dental
caries (d/D
component of
dmft/DMFT).
score.
•
BMI-for-age zscore.
•
pufa/PUFA score.
disturbance.
•
Sleeping
•
•
Parental height,
weight.
History of past
nutritional status.
Sociodemographic
characteristics.
disturbance.
46
Conversion of height and weight measures
into Z scores
• Z scores of ht, wt and BMI will be calculated by using WHO standard
references 2007 (children older than 5 years old). The BMI Z scores
will be calculated using Stata 13 and a Stata add-in called zanthro
(Vidmar et al. 2013).
• Z-scores will allow comparisons of individual’s weight, height or BMI,
adjusted for age relative to a reference population, expressed in
standard deviations (SD) from the reference mean.
DMFT/dmft index
48
PUFA/pufa index- clinical consequences of untreated
dental caries (Monse et al. 2010)
49
Study measures
50
SOHO-5 child questionnaire
Seven questions to assess oral health-related impacts:
• Eating
• Drinking
• Speaking
• Playing
• Sleeping
• Avoiding smiling (due to appearance and due to pain)
51
Child questionnaire
Answer options
52
Parental questionnaire
Seven questions to assess oral health-related impacts:
•
•
•
•
•
•
Eating
Speaking
Playing
Sleeping
Avoiding smiling (due to appearance and due to pain)
Self confidence.
Answer options
1.not at all, 2.alittle, 3.moderate, 4.alot, 5. a great deal.
53
Why SOHO-5?
• Both self-reports and parental proxy reports.
• Internally consistent and valid questionnaire (Tsakos et al. 2012).
• Tested and validated in Brazil, showing agreement in
mother and child responses (Abanto et al. 2014).
• Responsive to change after treatment of dental caries
(Abanto et al. 2013).
• Short, with child friendly answer options.
54
Data Analysis plan
• Data will be analysed using Stata version 13.0.
• For objective 1, the Bengali versions of the child and
parental SOHO-5 questionnaires will be assessed for their
validity and reliability.
55
Data Analysis plan (continue)
Descriptive
statistics
Assessment of
crude
association
Final
multivariable
association
• Frequency distributions of main exposure, outcome variables,
mediators and covariates.
• Mean/median of d/D component of dmft/DMFT, pufa/PUFA and
mean values of all outcome measures, mediators and covariates.
• Distribution of outcome and exposure variables by mediators and
covariates will be explored.
• Appropriate regression analysis methods will be used to assess
the associations of interest, taking potential confounding factors
into account.
56
Data Analysis plan (continued)
• Each outcome (height, weight and BMI-Z-scores) will be assessed
separately, by d/D component of dmft/DMFT and pufa/PUFA score.
• Model 1: unadjusted.
• Model 2: Adjusted for demographics, then socioeconomic and then
other covariates. .
• Model 3: Model 2 + OHRQoL scores.
• Model 4: Model 2 + dental pain, appetite, eating and sleeping
difficulties. These variables will first be examined separately, followed
by mutual adjustment to assess their relative contribution.
57
Pilot study
58
Objectives of the pilot study
1. To assess whether the research protocol is realistic and workable.
2. To test the adequacy, feasibility and appropriateness of the research
instruments.
3. To test the appropriateness and length of the questionnaire.
4. To assess the likely success of proposed recruitment approaches.
5. To identify and resolve any potential logistical problems before running
the main study.
6. To finalize the sample size calculation.
59
Results from pilot study
• Pilot sample size: 272 children.
• 127 from hospital setting.
• 145 from primary school.
• 97 (35.7%) boys and 175 (64.3%) girls.
• Mean age of all children: 7.4 years (SD= 1.2).
60
Table 1: Family socio-economic characteristics: hospital vs.
school sample
Hospital group
Father’s education
Monthly gross
family Income
School group
No institutional
education
13%
1%
More than higher
secondary level
26%
41%
Lowest income
group (less than
8000 BDT)
19%
7%
Highest income
group (More than
30 thousand BDT)
5%
22%
61
Table 2: Caries distribution in the sample
62
Table 3: Mean weight and height, by caries experience and
setting
63
Table 4: Tertile distribution of dental caries and height, weight
and BMI z scores
DMFT+dmft
tertiles
Group 1 (0-1)
N/n
85
Mean height
z score*
-0.02
Mean weight
z score*
0.05
Mean BMI
z score*
0.07
Group 2 ( 2-4)
83
-0.14
-0.27
-0.29
Group 3 (5max)
73
-0.67
-0.85
-0.66
64
Sample size calculation
• To have 80% power of demonstrating a statistically significant
difference of 1/3 of a standard deviation, at 95% level of significance
and 5% deviation from the true value the minimum required sample
size is 435 children.
• Assuming a response rate of 60% (following the results from the pilot
study), the final total estimated sample size is 696. The Open Epi
version 3 online calculator has been used for this calculation (Dean et
al. 2015).
65
Feedback from pilot study
• General observation (examiners/interviewers).
• Feedback from pilot study participants regarding their
understanding of the questions, difficulties related to
question wordings, and their ability to answer all
questions.
66
Feedback from pilot study (continued)
• The pilot study proved the overall feasibility of the
procedures adopted for the study.
• It took no more than 15 minutes to complete the parental
questionnaire.
• The pilot study has identified some potential difficulties and
resulted in some minor modifications of the procedures
and questionnaires.
67
Changes following pilot study
 Change in the parental questionnaire administration
• from interview administered to self administered
 Changes in questionnaire:
• Past nutritional status – change in question wording.
• Chewing difficulty – change in question wording.
• Additional sleep disturbance question – change in answer
options.
68
Challenges encountered in pilot study
• The political unrest in Bangladesh.
• Lack of proper lighting in the class rooms.
• Uneven floors in some classrooms.
• Separate section for boys and girls in different shifts.
• Low attendance rate of the parents for the interview.
69
Future Work Plan
70
Gantt chart for the rest of the PhD
71
Acknowledgements
• My supervisors.
• Commonwealth scholarship commission.
• Supporting people in UCL: Dr Antiopi Ntouva, Jess Porter,
Dr Manu Mathur, PhD students in Dental Public Health
group.
• Survey team in Bangladesh.
• All the study participants.
• My family members.
72
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Thank you
masuma.mishu.10@ucl.ac.uk
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